APPENDIX D Informed Consent Form

APPENDIX D

Informed Consent Form

INFORMED CONSENT FORM

The Administration for Native Americans and the Office of Planning, Research, and Evaluation, both within the Administration for Children and Families (ACF) within the U.S. Department of Health and Human Services, wants to learn about urban Indians’ perceptions of and experiences with ACF-funded services. The discussion you will be participating in will help ACF understand some of the barriers to service use and ways in which they might be able to change their services to better meet the needs of urban American Indians and Alaska Natives.

Your participation is voluntary and you have the right to stop at any time. You may also decline to answer any questions that are asked. The risk to you as a participant is minimal and may involve a breach of privacy. However, researchers will take steps to prevent this from happening. You will not be identified by name in any of our reports. Your information will be combined with information from other participants in other discussions and presented in summary form to ACF.

With your permission, this discussion will be audio-recorded. This recording is to ensure that the researchers accurately represent your views and opinions when they write their reports for ACF.

The information you provide in this discussion will be kept private to the extent permitted by law. Information collected during this discussion will be destroyed no later than 6 months after Westat’s contract with ACF has ended.

There are no direct benefits to you for participating. However, your views will contribute to ACF understanding how it may be able to better meet the needs of American Indians and Alaska Natives who are living in urban areas.

We will need no more than 60 minutes of your time.

The researcher will be happy to answer any questions you have about the study.

I have read and understand the statements above. All of my questions have been answered to my satisfaction. I consent to participate in this study.

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Participant's signature Participant’s printed name Date

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Researcher’s signature